R. Mohsine

Rupture intrapéritonéale du kyste hydatique du foie

Resume La rupture kystique represente Ia principale complication du kyste hydatique du foie et interesse 15 a 40 % des kystes. Dans de 2 a 7 % des cas le kyste hydatique du foie se rompt dans la grande cavite peritoneale. La survenue d’une peritonite encapsulante secondaire a la rupture du kyste hydatique du foie n’a ete decrite, a notre connaissance, qu’une seule fois. Nous rapportons l’observation d’une patiente de 43 ans chez qui le diagnostic de rupture peritoneale d’un kyste hydatique du foie est fait apres 3 mois. La malade etait mise sous traitement medical a base d’albendazole (10 mg/kg/j). Deux mois apres le debut de ce traitement, la malade etait operee. On a decouvert d’une peritonite encapsulante. Les differents prelevements realises pour etude parasitologique etaient negatifs. Le geste chirurgical a consiste en un lavage a l’eau oxygenee de la coque fibreuse de la peritonite encapsulante et un drainage sans aucune dissection. L’evolution a ete satisfaisante sous traitement par l’albendazole pendant 14 mois. Actuellement, elle est en bonne sante sans recidive et sans trouble du transit avec un recul de 2 ans. Nous pensons que l’albendazole est tres efficace dans le traitement de la maladie hydatique a condition de l’administrer de facon continue le plus longtemps possible. La survenue d’une peritonite encapsulante est heureusement une situation exceptionnelle dont la prise en charge chirurgicale est tres delicate.

Thyroid Tuberculosis: Diagnosis and Treatment

Objective: It was the aim of this study to report clinical characteristics and treatment of thyroid tuberculosis (TT). Methods: During 16 years, 2,426 patients have been operated on the thyroid in the surgical department ‘A’ in Ibn Sina Hospital, Rabat, Morocco. Anatomopathological results of the removed thyroid were analyzed for evidence of tuberculosis. Results: Eight cases of TT were diagnosed. Five patients had a goiter and 3 patients had an isolated nodule of the thyroid. In one case, fine-needle aspiration cytology gave the diagnosis of TT. This patient had a complete drainage of the abscess. In all other patients, the diagnosis was given after surgery. All patients received additional antituberculous drugs for 6 months, and follow-up was satisfactory. Conclusion: TT does not have any consistent symptoms. Fine-needle aspiration is the best method for diagnosis and can result in the avoidance of surgery.

Surgery in Intra-abdominal Ruptured Hydatid Cyst

In a recent original article, Derici et al. reported an interesting study on 17 hydatid disease cases with a rupture in the peritoneum [1]. We think that some points regarding hydatid rupture need to be made clear. We would like to underline that urgent surgery should be minimized after diagnosing hydatid cyst rupture. It is well established that liver hydatid cyst rupture incidence represents 15%–40% of all cases, and 2%–7% of cysts can become perforated in the peritoneum [2]. In this situation, the rupture requires emergency care because allergic reactions or anaphylactic shock may develop in up to 25% of the cases [1]. In their report, Derici et al. did not mention their 17 patients’ hemodynamic status or body temperature. Nor did they specify whether the patients had jaundice or peritonitis with or without sepsis. Hydatid cyst rupture itself, does not compel us to initiate emergency operation unless the patient’s clinical status requires immediate action. Thus we believe it is important to report the patients’ clinical and biological status. It is also important to discuss the time from onset of symptoms to emergency unit consulting and operation. Cholangitis, sepsis, acute abdomen status, intraperitoneal bile leak, extensive inflammatory reaction, and shock as consequence of or associated with rupture(trauma) are all reasons for urgent surgery. However, if the patient is not suffering from a critical illness, the operation can be postponed to a better moment. Albendazole may play an interesting role in the management of patients with hydatid cyst rupture [2] by neutralizing liquid parasitological activity from the cyst. Another possible side effect is sclerosing peritonitis [2], in which case percutaneous drainage of the intraperitoneal fluid could be performed. Peritoneal fibrosis reaction and albendazole could prevent new hydatid cyst formation from floating daughter cysts. Although, hydatid disease is often asymptomatic, it can sometimes cause difficult complications that can lead to death. More studies are needed to clarify the mechanisms that control the allergic phenomena produced by hydatid disease [3]. After liver hydatid cyst intaperitoneal rupture, mortality rate climbs to 6% and morbidity averages 20%– 35% [4].

Radical versus conservative surgical treatment of liver hydatid cysts.

The management of liver hydatid cysts is controversial. Surgery remains the basic treatment, and can be divided into radical and conservative approaches. The purpose of this study was to compare the results of radical and conservative surgery in the treatment of liver hydatid cysts.

Changing paradigms in the surgical management of cystic liver hydatidosis improve the postoperative outcomes

AIM OF THE STUDY Our aim was to propose and examine the outcomes of a comprehensive strategy for the management of cystic liver hydatidosis (CLH) based on extensive intraoperative assessments and optimal management of cystobiliary communications. BACKGROUND DATA Although operative intervention remains the preferred treatment for CLH, and the presence of a cystobiliary communication remains a well-established predictive factor for postoperative complications, no internationally accepted management strategy integrates the specific management of cystobiliary communication into the choice of surgical approach. METHODS Early postoperative outcomes were compared before (1990-2004; P1 group; n = 664) and after (2005-2013; P2 group; n = 156) the implementation of a CLH surgical management strategy for CLH in our overall group of patients in subgroups selected by risk factors (as determined by multivariate analysis), and in 2 propensity score-matched groups. RESULTS Specific complications related to the hepatic procedure (intraabdominal complications) were independently associated with the presence of ≥ 3 cysts (P = .013), a fibrotic pericyst (P = .005), a cystobiliary communication (P < .001), and the P1 treatment period (P = .002). Between P1 and P2 groups, the rate of specific complications decreased in the overall group of patients with CLH (18.3% vs 4.5%; P < .001). The rate also decreased in risk factor-based subgroups: patients with ≥ 3 cysts (31.0% vs 4.0%; P = .005), a fibrotic pericyst (23.1% vs 9.2%; P = .011), and a cystobiliary communication (33.0% vs 13.2%; P = .006). After propensity score matching among 123 well-balanced matched pairs of patients, the overall complication rate, specific hepatic surgery-related complication rate, and median duration of hospital stay decreased between the P1 and P2 groups: 23.6% vs 12.2% (P = .02), 21.1% vs 4.9% (P < .001), and 7 vs 5 days (P < .001), respectively. CONCLUSION Implementation of a CLH surgical management strategy based on specific intraoperative assessment and optimal management of cystobiliary communications improved early postoperative outcomes.

A rare tumor of the thyroid gland: report on one case of leiomyosarcoma and review of literature.

Despite the fact that 15–20 % of sarcomas occur in the head and neck and 80 % in adults, only 0.014 % of leiomyosarcomas develop in the thyroid gland level. To the best of our knowledge, only 17 cases have been reported worldwide [1]. Leiomyosarcomas are difficult to diagnose preoperatively. The treatment of choice for leiomyosarcoma of the thyroid is not yet well established because of its poor prognosis. We report a case of primary leiomyosarcoma of the thyroid gland in a male patient with review of the literature.

Acute abdominal compartment syndrome complicating a colonoscopic perforation: a case report

IntroductionA perforation occurring during colonoscopy is an extremely rare complication that may be difficult to diagnose. It can be responsible for acute abdominal compartment syndrome, a potentially lethal complex pathological state in which an acute increase in intra-abdominal pressure may provoke the failure of several organ systems.Case presentationWe report a case of acute abdominal compartment syndrome after perforation of the bowel during a colonoscopy in a 60-year-old North African man with rectal cancer, resulting in respiratory distress, cyanosis and cardiac arrest. Our patient was treated by needle decompression after the failure of cardiopulmonary resuscitation. An emergency laparotomy with anterior resection, including the perforated sigmoid colon, was then performed followed by immediate anastomosis. Our patient remains alive and free of disease three years later.ConclusionAcute abdominal compartment syndrome is a rare disease that may occasionally occur after a colonoscopic perforation. It should be kept in mind during colonoscopy, especially considering its simple salvage treatment.

Actinomycose digestive: Trois cas et revue de la litérature

Resume L’actinomycose est une affection chronique suppurative. Elle est causee par une bacterie anaerobie, le plus souvent Actinomyces israelii. Les localisations cervicales et thoraciques sont les plus frequentes. L’actinomycose digestive est rare et peut simuler un cancer conduisant a une intervention chirurgicale avec resection. Nous rapportons trois observations d’actinomycose abdominale. Il s’agissait d’une localisation colique dans deux cas et d’une localisation hepatique dans un cas. Tous les malades ont ete operes. Le diagnostic d’actinomycose a ete pose en post-operatoire dans les trois cas. L’evolution a ete favorable sous traitement medical. Ces observations illustrent les difficultes diagnostiques de cette maladie rare et meconnue dont le traitement est essentiellement medical reposant sur une penicillinotherapie prolongee.

Impact of seniority on operative time and short-term outcome in laparoscopic cholecystectomy: Experience of an academic Surgical Department in a developing country.

Introduction: Resident participation in laparoscopic cholecystectomy (LC) is one of the first steps of laparoscopic training. The impact of this training is not well-defined, especially in developing countries. However, this training is of critical importance to monitor surgical teaching programmes. Objective: The aim of this study was to determine the impact of seniority on operative time and short-term outcome of LC. DESIGNS AND SETTINGS: We performed a retrospective study of all consecutive laparoscopic cholecystectomies for gallbladder lithiasis performed over 2 academic years in an academic Surgical Department in Morocco. Participants: These operations were performed by junior residents (post-graduate year [PGY] 4–5) or senior residents (PGY 6), or attending surgeons assisted by junior residents, none of whom had any advanced training in laparoscopy. All data concerning demographics (American Society of Anesthesiologists, body mass index and indications), surgeons, operative time (from skin incision to closure), conversion rate and operative complications (Clavien–Dindo classification) were recorded and analysed. One-way analysis of variance, Students t-test and Chi-square tests were used as appropriate with statistical significance attributed to P < 0.05. Results: One hundred thirty-eight LC were performed. No differences were found on univariate analysis between groups in demographics or diagnosis category. The overall rate of operative complications or conversions and hospital stay were not significantly different between the three groups. However, mean operative time was significantly longer for junior residents (n = 27; 115 ± 24 min) compared to senior residents (n = 37; 77 ± 35 min) and attending surgeons (n = 66; 55 ± 17 min) (P < 0.001). Conclusion: LC performed by residents appears to be safe without a significant difference in complication rate; however, seniority influences operative time. This information supports early resident involvement in laparoscopic procedures and also the need to develop cost-effective laboratory training programmes.

Post-traumatic arteriovenous fistula of the hepatic pedicle

Hepatico-portal fistula (HPF) is a rare condition, most often of post-traumatic or iatrogenic origin and occasionally secondary to a ruptured aneurysm of the hepatic artery into the portal vein. HPF in extrahepatic locations often results in portal hypertension (PHT). While Doppler ultrasound, CT angiography, and magnetic resonance angiography are usually demonstrative, arteriography remains indispensable to clarify the exact anatomical configuration. In the treatment of these arteriovenous (AV) fistulas, open surgical approaches have increasingly given way to radiological embolization techniques, especially in intrahepatic locations, but surgery remains indicated for AV fistulas of the hepatic pedicle where maintenance of hepatic arterial flow is a priority of treatment. We report a patient who had an AV fistula of the hepatic pedicle with resultant PHT presenting 5 years after open abdominal trauma. Treatment was surgical; the immediate and long-term postoperative course was uneventful with regression of PHT. Through analysis of this case and a review of the literature, we discuss the clinical, paraclinical, therapeutic, and prognostic features of this lesion.